Application for Free AstraZeneca Medicines

1 Application for free AstraZeneca Medicines :Specialty Care ProductsPO Box 898, Somerville, NJ 08876 How to Complete this Application : 1. Review the information on this page carefully and keep it for your Complete pages 3, 4 and 5 of the Gather the required documentation listed on page Mail or fax your completed Application and required documentation following the instructions on the next are the AZ&Me Prescription Savings Programs? The AZ&Me Prescription Savings Programs (the Program) are a group of programs offered by AstraZeneca that allow you to get free Medicines if you qualify.

2 It is neither a government program nor an insurance plan If you qualify, you may get free AstraZeneca medicine for up to 1 year, depending upon the Program in which you are enrolled. AstraZeneca will send you an Application for renewal once your enrollment ends Most Medicines will be sent to your home. Some Medicines will be sent to your doctor s office due to specific handling requirements Our Specialty Care Medicines are sent in a 30-day supplyWho is AstraZeneca ? AstraZeneca is a company that makes prescription Medicines AstraZeneca has offered prescription savings programs to people who qualify since 1978 The Program can be changed or stopped by AstraZeneca at any time or for any you qualify for the Program?

3 You may qualify for the Program if:3 You are a US Citizen, or a Green Card or Work Visa holder3 You meet certain household income limits (visit or call 1-800-AZandMe for details)3 And one of the following applies: n You do not have prescription drug coverage that helps pay for your AstraZeneca Medicines n You participate in Medicare Part D and have spent at least 3% of your total household income on prescription Medicines through a Medicare Part D Prescription Drug Plan during the current year n You are requesting assistance with a medication that is covered under Medicare Part B and you have spent at least 3% of your total household income on prescription Medicines through your Medicare benefit during the current yearThe Affordable Care Act has created

4 A marketplace of Health Insurance Exchanges where uninsured individuals and families are able to purchase healthcare coverage, the cost of which may be subsidized for qualified enrollees. More information about these plans can be found at review the checklist on the next page to ensure that your Application is complete and ready for for free AstraZeneca MedicinesSpecialty Care ProductsPage 2 of 5AZ&Me Prescription Savings Program Application ChecklistThe following items must be submitted by mail or by fax to complete your Application , even if you have completed the Application online.

5 Keep this page for your ALL the following TOGETHER:n A completed Application , signed and dated by you and your prescriber Blank applications can be found on This Application is for our Specialty Care Medicines , including CALQUENCE (acalabrutinib), FASENRATM (benralizumab), FASLODEX (fulvestrant), IMFINZI (durvalumab), IRESSA (gefitinib), LYNPARZA (olaparib) and TAGRISSO (osimertinib). There are applications for our other products available on The completed prescription on page 3 of this applicationn Proof of household income (include only one of the following).

6 A copy of last year s federal income tax returns for yourself, spouse, and dependents All income statements from jobs last year (W2 or 1099) Two current paystubs Current Social Security Income Yearly Benefits Statement If current household income is zero, a letter explaining your financial situation from a family member, healthcare provider, or yourselfn If you are a Medicare Part B or Medicare Part D enrollee, please also include: A copy of the front and back of your Medicare Rx card (for Part D) or your Medicare enrollment card (for Part B) A copy of your Medicare Part B and/or Medicare Part D Prescription Drug Plan statement (Explanation of Benefits [EOB]), a pharmacy printout, or a summary document from your pharmacy indicating the amount you have spent for prescriptions in the current calendar year.

7 This total should be at least 3% of your incomePlease do not send your medical records or Statement of Medical Necessity form with your your completed Application , prescription, and required proof of income documentation to:AZ&Me Prescription Savings ProgramPO Box 898 Somerville, NJ 08876 OrYour doctor s office may FAX your completed Application , prescription and required documentation, with a fax cover sheet. For FASENRATM (benralizumab), SYNAGIS (palivizumab) or IMFINZI (durvalumab): 1-855-686-8795. For CALQUENCE (acalabrutinib), FASLODEX (fulvestrant), IRESSA (gefitinib), LYNPARZA (olaparib), or TAGRISSO (osimertinib): 1-877-239-0867.

8 applications and prescriptions not faxed from the doctor s office will be deemed Information about your ApplicationInformation provided to us will be used to determine possible eligibility for help from another program such as Medicaid. You may be required to submit documentation supporting that you do not qualify for other prescription assistance. For Prescription Refills, call 1-800-292-6363 Once you are enrolled in the Program, your prescriptions can easily be refilled by calling our automated phone line 24 hours a day, 7 days a Call 1-800-292-6363 or visit US-18512 3/18 Monday - Friday, 9:00 am to 6:00 pm ETApplication for free AstraZeneca MedicinesSpecialty Care ProductsPage 3 of 5 Prescription InformationPATIENT INFORMATION: Please print clearly in blue or black Security Number: _____-_____-_____ Date of Birth.

9 _____/_____/_____ (This information will only be used to determine eligibility.) (MM/DD/YYYY)Name: _____ First Middle Initial Last Address: _____ City: _____ State: _____ Zip: _____n Patient has no current address. (Medication will be shipped to HCP s office) Phone: ( _____ ) _____ Alternate Phone: ( _____ ) _____ E-mail: _____n New Application n Re-enrollment PRESCRIBER INFORMATION: This form will replace all previous prescriptions that may have been sent. All fields are required, eg, BRAND NAME, strength, directions for use, quantity, and refillsPrescriber Name: _____ Phone: ( _____ ) _____Fax: ( _____ ) _____Address: _____ City: _____ State: _____ Zip: _____ DEA: _____ NPI:_____ State License Number (SLN): _____Office Contact Name: _____ Phone: ( _____ ) _____Please select a medication:Strength:Directions:QTY:Refil ls:SHIP MEDICATION TO: n PATIENT n PRESCRIBER*(*For Prescribers in Ohio ONLY.)

10 Pursuant to OAC 4729-5-10, Ohio prescribers must be approved by the Ohio Board of Pharmacy to be a pick-up station)Prescriber Signature: _____ Date: _____ NY Prescribers must attach a separate prescription in accordance with NY pharmacy ID: _____PLEASE NOTE: Medications cannot be shipped to Post Office (PO) Name: _____Questions? Call 1-800-292-6363 or visit US-18512 3/18 Monday - Friday, 9:00 am to 6:00 pm ETn CALQUENCE (acalabrutinib) Capsulesn FASLODEX (fulvestrant) Injectionn IRESSA (gefitinib) Tabletsn TAGRISSO (osimertinib) Tabletsn FASENRATM (benralizumab) Injectionn IMFINZI (durvalumab for infusion)n LYNPARZA (olaparib) TabletsProgram Eligibility Information: Please print clearly in blue or black : _____ Social Security Number.